Food Impaction:
Food impactions are the most common cause of esophageal obstruction in western countries. Evaluating patients with possible impactions and prompt endoscopic management are keys to avoiding bad outcomes.
Follow the link below to see ASGE Guidelines on this topic
Document link: Management of ingested foreign bodies and food impactions Gastrointest Endosc 2011:73:1085-1091 / DOI: http://dx.doi.org/10.1016/j.gie.2010.11.010
Initial Evaluation:
Airway: Most important part of evaluation. Is the patient able to manage their own secretions or are they at risk for aspiration. This will also determine choice of sedation for any endoscopy
What and when: Establishing what the patient ingested and how long ago is important. Depending on the type of food swallowed and if it may have bones or other portions which increase risk of perforation. Timing is important as well. The longer the impaction is present the risk for perforation and the difficulty of endoscopy increase
Past history: Many cases of food impaction are due to underlying esophageal pathology. This includes strictures, stenosis, hiatal hernias and EOE to list a few. Knowing if the patient has any of these prior to a procedure is important
Physical Exam: Look for signs of aspiration. Also examine for crepitus and abdominal pain which could suggest perforation
Imaging:
Do not order a barium swallow
If a bone or other foreign object is suspected CXR or CT should be ordered to evaluate for possible perforation. CT is better at identifying radiolucent objects such as small bones
No imaging is needed if confident non-bony food impaction is present
Treatment and Timing:
Once patient is evaluated and perforation ruled out the next step is endoscopy. The sooner the better in terms of timing for both completely obstructing and partially obstructing food impactions. The figure on the right is from the ASGE guidelines on management of ingested objects.
What about Glucagon? Glucagon has been used with the thought that it relaxes the LES allowing for the food bolus to pass into the stomach. A large case control study evaluated 222 cases of food impaction and the 106 of those who received glucagon. Out of the 106 who received glucagon 10 had a response and did not require endoscopy. ASGE recommends that Glucagon 1mg IV can be trialed but should not delay endoscopy
Sodeman, T.C., Harewood, G.C. & Baron, T.H. Assessment of the Predictors of Response to Glucagon in the Setting of Acute Esophageal Food Bolus Impaction . Dysphagia 19, 18–21 (2004). https://doi.org/10.1007/s00455-003-0019-5Endoscopic Therapy & Strategies:
Pushing bolus into the Stomach : Newer recommendations suggest that gentle pressure pushing a food bolus into the stomach is safe even without looking past the bolus is safe. This was based on 2 studies that showed no perforations out of 375 patients where the technique is used. However gentle pressure is subjective and operator variations must be considered prior to any technique.
Ginsberg GG. Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995;41:33-8. , Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc 1983;29:208-10.Breaking down the food bolus : Breakdown of the bolus via piecemeal removal. Endoscopists have many tools at their disposable including snares, biopsy forceps, roth nets, rat-tooth forceps and newer suction caps to break down a bolus.
Impaction cleared now what? Its important to examine the esophagus for pathology following clearing of bolus. Stricture can be possible following removal but one must take into account any esophageal injury and duration of impaction. Biopsies for EOE should be obtained if suspected
Other Considerations: If concern for sharp objects or prolonged procedure breaking down a food bolus an overtube can be used to protect the esophagus and airway during endoscopy. It also facilitates passing the scope into the GI tract multiple times. A foreign body protector hood can also be equipped to protect the esophagus when removing sharp and pointed objects.
Overtube
Foreign body hood
